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MORBID OBSESSIONS

by Fred Penzel, Ph.D.

"Doctor," began Alex, "1 don't know if anyone can help me. I think I must be some kind of incurable psychopath. You know, the kind you hear about on the news, who just goes berserk for no good reason and kills someone. Whenever I'm alone with someone older or smaller or weaker than me, I can't stop thinking about harming or even killing them... I mean, children, or some of my elderly estate planning clients, or even my wife, or other people who I don't even know!"

Staring at my office floor and speaking in a hushed voice, he went on to say, "1 get thoughts about putting my hands around their throats and choking them, or else I think about punching them in the face, or even pushing them out of windows. I go to work by rail and, when I stand on the platform, I think about pushing people in front of moving trains. I can't even eat in restaurants anymore. I can't stop thinking how easy it would be to stab the waitress with the knives or forks. I keep telling myself that I'm a good person who has never hurt anyone in his whole life. I don't want to think of doing these things, but I just can't block them out of my brain!"

What could possibly have induced this mild looking thirty-six year old financial planner to think this way?

"The first psychiatrist I went to said he thought I suffered from schizophrenia," Alex continued. "He gave me some anti-psychotic medication that made me feel so drugged that it was as if I was walking underwater all day. The last therapist I went to made things even worse. He told me that I must be holding in a lot of anger and that these thoughts were really my unconscious wishes. He said I would have to work out some early conflicts in my life to get rid of the anger, and that would take a long time. I asked him, 'In the meantime, how can I really be sure that I won't go berserk and do the things I'm thinking?' And he nodded at me and gave me nothing as an answer!"

I tried to assure Alex that, despite his fears and his past misdiagnoses, he was not a 'psycho-killer: but was suffering from Morbid Obsessions, one of the more misunderstood forms of the complex illness known as Obsessive-Compulsive Disorder, or OCD. Despite the fact that this illness afflicts at least one out of forty people, it is one of the more poorly diagnosed problems seen by clinicians. For those who are not personally acquainted with such obsessive thoughts, we must be careful here to define what they are. Simply put, obsessions are any thoughts which cause anxiety, which are intrusive and repetitive, and which the thinker believes to not be his or her own and which they attempt to resist. Unlike those persons afflicted with schizophrenia, OCD sufferers are not delusional or hallucinatory. Their thinking is not disorganized. One of my patients refers to them as " my synthetic thoughts."

It was clear that Alex did not wish to harm anyone. He was simply unable to screen out thoughts of doing so. Most people with OCD, like Alex, almost universally begin describing their symptoms with the phrase, "I know this sounds crazy, but They exist in an isolated world of silent anguish, fearful of exposing this other thought process existing in their minds. They live in dread that the label 'insane' or 'psychotic' will be attached to them, if they share their thoughts with anyone, even a professional.

One woman related to me that her psychologist, in his ignorance, had actually reported her to state protective child services when she revealed her morbid obsessions about harming her children.

Obsessions are frequently accompanied by compulsions, which are any mental or physical activities done to reduce anxiety caused by the obsessions. These can range from simple avoidance to complex rituals of a superstitious and magical nature, which can take hours to perform.

While OCD was once thought to be strictly psychological in origin a type of neurosis it is now being recognized as a neurobiological disorder with a possible genetic basis. OCD can enter a person's life at an early age. According to NIMH figures, nearly ten percent of those who ever have it are already showing signs between the ages of five and ten. By the age of twenty, this figure rises to over forty percent. Until symptoms begin to emerge, it exists as "a potential" people carry around with them an accident waiting to happen. There are quite a few different categories of obsessions. Most of them revolve around either the thinker's harming someone else, or having harm happen to themselves. Alex's category, which is not uncommon, includes thoughts of killing, mutilating and injuring others or himself. These others can be loved ones, acquaintances or merely strangers.

Alex's morbid thoughts appeared to have really begun affecting his life when he turned thirty, just around the time he began his new career. This was a stressful time for him, he acknowledges, and the point at which he believes his illness began. On close questioning about his early years, he remarked that, ". It's funny, but now that we're talking about it, I remember that I used to sit at my desk in high school and think that I could stick my pencil in my eye and blind myself. Sometimes when I was slicing food, in the kitchen at home, I would get these ideas about cutting up my parents. I guess the thoughts weren't very strong, at the time, because I was able to push them away."

The recent upsurge in the punishing thoughts afflicting Alex began one night when he and his wife were lying in bed. "Suddenly it came into my mind how easy it would be to put my hands around Jessica's throat and strangle her to death. She is a lot smaller and weaker than me, and I knew she couldn't stop me. I could see myself doing it, and I imagined how she would struggle and then go limp. I told myself that this was totally stupid and unreal, but the thoughts just wouldn't go away:' The thoughts came back the next night, and every night there-after for several weeks. Alex began to dread this time of day. "I tried lying there all night, clasping my hands, and praying to God not to lose control. Eventually I began sleeping in our spare room, and told my wife I was just having trouble sleeping and didn't want to wake her up. I mean, how could I tell her what was going on in my head? I kept hoping that the thoughts would just go away."

As time went on, the thoughts not only didn't cease, but began to spread to many other situations with his wife and, later, with others. "Whenever we rode in the car together it would start up again, with me thinking how easily I could just do all these horrible things to her. I would try to grip the steering wheel really tight and force myself to concentrate solely on the road. But the thoughts were increasingly sinister and would almost seem to talk back to me every time I told myself that they were ridiculous, they would come back even stronger. They would make me think, 'Yeah, but how do you know for sure that you really don't want to do this?' And I would ask myself, why else would I be thinking about it all the time?"

At the start of his treatment, Alex had been about ready to give up. He had begun seeing a new psychiatrist, on his own, several weeks before he first came to see me. He was taking an antidepressant, which lessened the thoughts somewhat, but still didn't take them away. Luckily his physician was aware of the value of behavioral treatment for OCD and urged him to take this next step, despite Alex's growing fear that nothing could help him.

"Don't bother trying to teach me to relax myself, or to snap a rubber band on my wrist when I get those thoughts;' he informed me, with what sounded like barely concealed sarcasm. "My first two doctors tried those already and they didn't even make a dent in all this." I explained to Alex that these were not currently considered to be useful treatments for this disorder. 'Actually," I told him, "We have a saying around here - "If you want to think about it less, think about it more." He looked a bit edgy, when I said this. "Were you ever successful at forcing yourself not to think the thoughts?" I asked.

"No;' he answered, "I just wound up thinking about them even more. I then asked him, "Have you ever stayed with the thoughts and remained in a fearful situation long enough to see what really happens?"

When he said he never had, I went on to describe a treatment known as Exposure and Response Prevention. This has been in existence for over twenty years. People are helped, in a step-by-step manner, to gradually face stronger obsessive thoughts while resisting the urge to do anything compulsive to relieve the anxiety. In this way they begin to build up a tolerance for the thoughts and eventually no longer feel anxious when they occur. They can acknowledge the thoughts, but do not feel as if they must react to them.

Morbid obsessions (as well as other types) have long been mistakenly labeled as hard to treat by practitioners and this is attributable mainly to three reasons:

First, the practitioners often fail to distinguish between obsessions and compulsions. While both are mental events, they are quite different in their functional relationship to each other. Some practitioners believe that the thoughts must be resisted or blocked out, in the same way as compulsions. Paradoxically, they cannot be suppressed and must be confronted.

The second reason is that many practitioners fall into the trap of being distracted by the nasty content of the thoughts, failing to recognize them as obsessions rather than true desires. When the thoughts are treated as genuine impulses, the practitioner often tries to help the person control them, or else gets lost in endless discussions of what the thoughts really mean. The harm this approach can inflict is immense, because it only helps to convince the patient that the thoughts have validity and that they are right to be worried about carrying them out.

The third reason is that even when practitioners have some knowledge, they are not effectively utilizing existing techniques to their fullest. While many will try to help patients resist compul-sions, they use ineffective or outmoded techniques for the obsessions, the way Alex's other doctor did. They may not even attempt to treat the obsessions at all, not realizing that the untouched obsessions will only go on to generate more compulsions.

The actual treatment is straightforward. Alex began to gradually expose himself to the thoughts, and to resist his accompanying compulsions. He learned that, instead of avoiding situations where he might harm others (such as when waiting for the train), he had to stand there and keep thinking about doing so, in order to see that his anxiety and preoccupation would truly subside. In this way, he would learn that he didn't have to escape or stay at home like a recluse. While he was told, only at the outset, that "people with morbid obsessions do not act them out," he was given no further reassurance of any kind. He was encouraged, instead, to stay with and feel the anxiety. Alex would attend weekly therapy sessions and, in between, carry out homework on his own at his own pace. The assignments were tailored just for him, and were based on a ranked listing of all the situations he feared.

One of our most important techniques was to use audio tapes, several minutes in length, several times a day. Other methods include reading books or articles that provoked his thoughts, writing essays on why the thoughts were really true, and putting himself in real-life situations among other people likely to bring the thoughts on.

In all, between the therapy and medication, it took Alex roughly nine months of daily hard work to reach a state of recovery. He had his good and bad days, but he persisted. He still experienced the occasional thought, but could now handle it as it was occurring. Towards the end of treatment, he shook his head, saying, "There were times when I thought you were the Stephen King of psychologists, making me face all of those creepy things. I guess I called you some pretty foul names, at times. I have to admit, though, that I really learned something. You genuinely gave me every opportunity to act on every horrible thing I thought of doing, and I didn't do any of them! I truly believe, now, that I won't do any of them, ever, and that I never really wanted to, either."

If you would like to read more about what Dr. Penzel has to see about OCD, take a look at his self-help book "Obsessive-Compulsive Disorders: A Complete Guide to Getting Well and Staying Well," (Oxford University Press, 2000. You can learn more about it at www.ocdbook.com